Surgical treatment of the diseases of neuronal networks

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2011.10.15.. TÁMOP – 4.1.2-08/2/A/KMR-2009-0006 1 Development of Complex Curricula for Molecular Bionics and Infobionics Programs within a consortial* framework**

Consortium leader

PETER PAZMANY CATHOLIC UNIVERSITY

Consortium members

SEMMELWEIS UNIVERSITY, DIALOG CAMPUS PUBLISHER

The Project has been realised with the support of the European Union and has been co-financed by the European Social Fund ***

**Molekuláris bionika és Infobionika Szakok tananyagának komplex fejlesztése konzorciumi keretben

***A projekt az Európai Unió támogatásával, az Európai Szociális Alap társfinanszírozásával valósul meg.

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BEVEZETÉS A FUNKCIONÁLIS NEUROBIOLÓGIÁBA

INTRODUCTION TO

FUNCTIONAL NEUROBIOLOGY

By Imre Kalló

Contributed by: Tamás Freund, Zsolt Liposits, Zoltán Nusser, László Acsády, Szabolcs Káli, József Haller, Zsófia Maglóczky, Nórbert Hájos, Emilia Madarász, György Karmos, Miklós Palkovits, Anita Kamondi, Lóránd Erőss, Róbert

Gábriel, Zoltán Kisvárdai, Zoltán Vidnyánszky

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Neurosurgery:

Surgical treatment of the diseases of neuronal networks

Imre Kalló & Loránd Erőss

Pázmány Péter Catholic University Faculty of Information Technology

I. Neurosurgical techniques

II. Application fields of neurosurgery 1. Neurooncology

2. Parkinson’s disease

3. Treatment of epilepsy

4. Treatment of pain

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Aims of the neurosurgical treatments

Treatment of patients suffering from neurological diseases, which can not be cured off or sufficiently well with conservative approaches. Improving life quality, preventing deterioration of disease state, extending the period of quality life, palliative treatment and alleviation of pain.

Factors influencing the therapeutic decisions of the neurosurgeon

• The preoperative clinical status of the patients

• Morphological data obtained with the modern imaging techniques

(preoperative, intraoperative)

• Data of functional imaging techniques (preoperative)

• Electrophysiological data (preoperative, intraoperative)

Specializations in neurosurgery

• Neurotraumatology

• Pediatric neurosurgery

• Vascular neurosurgery

• Spinal neurosurgery

• Functional neurosurgery

• Neuro-oncology

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Neurosurgical techniques Minimally invasive

surgical techniques

• From the brain point of view

• From the patient’s somatic point of view

• Or from the patient’s psycho- somatic point of view

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Neurosurgical techniques

Microscope-assisted intracysternal, or gyral

microsurgery

Endoscopic neurosurgery

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Neurosurgical techniques

Stereotaxic

neurosurgery Neuronavigation- and robot-assisted microsurgery

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Neurosurgical techniques:

neuronavigation

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Neurosurgical techniques: neuronavigation

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Image guided neurosurgery

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Neurosurgical techniques: gamma ray surgery

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Gamma knife

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Neurosurgical techniques: linac and cyberknife

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Neurosurgical techniques: radiation surgery

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Neurosurgical techniques: robot-assisted surgery

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Neurosurgical techniques: endovascular neurosurgery

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Neurosurgical techniques: preoperative imaging

• CT • MR

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Neurosurgical techniques: preoperative imaging

• MR tractography

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Neurosurgical techniques: intraoperative imaging

• Focused UH surgery

• Open MRI

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Neurosurgical techniques: intraoperative imaging

• Functional MR

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Neurosurgical techniques: intraoperative imaging

• Functional MR: finger tapping

Photo by Lajos Kozák /MRKK

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Application fields: neuro-oncology

Complex treatment of CNS tumors

• Diagnostics: Is it tumor?

Histology?

• Therapy: surgical

radiation therapy chemotherapy

• Supportive therapy, care

• Clinical research

Significance

• Potentially life-threatening disease

• Number of patients with brain tumors ↑

• Number of surviving

oncological patients ↑

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Application fields: neuro-oncology

CNS tumors

• 1.5% of all malignant tumors

• 2-2.3% of all causes of death

• 2.1% of death caused by tumors

• Neuroepithelial (intrinsic) tumors (48%)

• Extraparenchymal tumors (40-45%)

• Metastase (5-10%)

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Neurosurgical techniques: stereotaxia

“The tools used by the surgeon must be adapted to the task and where the human brain is

concerned they cannot be too refined.”

Lars Leksell, M.D., Ph.D., 1907-1986

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Neurosurgical techniques: stereotaxia

Aim:

Targeting normal or pathological brain regions by using their 3D coordinates determined before with precise imaging techniques.

Tool:

Stereotaxic targeting instrument

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Leksell stereotaxic instrument

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Application fields of the stereotaxis

Parkinson’s disease and other movement disorders Surgical treatment of epilepsy

Surgical treatment of pain

Treatment of abscesses, intracerebral haematoms, cysts, tumors

Implantation of radioactive izotops (e.g. Yttrium 90) into the

tumor

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Application fields: Parkinson’s disease

z

Ablative surgical techniques

z

Stimulation techniques

z

Transplantation techniques

Intracerebral navigation with a microelectrode

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Intracerebral navigation with a microelectrode ?

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Surgical treatment of epilepsy

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Probability of seizure in diagnosed epilepsy

(Brodie, Kwan NEJM 2000)

Before the first drug treatment 64%

Before the second drug treatment 32%

After the second drug treatment 9,6%

In case of politherapy 3%

Surgical treatment of epilepsy

Pharmacological treatment

Neuromodulation Surgical

treatment

Aim:

To improve the psychosocial status of the patient by the abolishment of seizures or by reducing the number of seizures or by changing the

seminology of the seizures.

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Surgical treatment of epilepsy

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Preoperative phase I.

• Aim: to set a hypothesis about the source of seizure

• Non-invasive phase:

• Search for lesion (MRI)

• Interictal and ictal EEG image

• Examining the functional state: building in interictal and ictal SPECT or maybe PET data

• Based on the convergence level of the data - lesionectomy

- lesionectomy oriented by the epileptogenic zone

- epilepsy surgery „sensu stricto„ (usually it requires further, invasive phase)

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Preoperative phase II.

invasive preoperative examinations

• Semi-invasive and invasive (subdural strip or grid, foramen ovale, or maybe intracerebral electrodes)

• Amytal test (dominant hemisphere, speech functions, memory)

• Decision: surgery? – what kind of surgery?

Surgery plan

• Aim:

Removal of the primary epileptogenic zone and/or the areas participating in the early spreading of the seizure, and the secundary „relay stations” e.g.:

amygdalo- hippocampal complex without the deficit of eloquent brain regions

• Forms: „standard resectio”

„tailored surgery”

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Aim of usage of invasive electrodes

3D spatial and temporal mapping of the site of origin and the spreading direction of epileptic seizures.

Semi-invasive and invasive electrodes

• Sphenoidal electrodes

• FO elektrode

• Strips, grids

• PEG electrodes ??

• Intracerebral (makro- and microelektrodes)

• SEEG

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Invasive electrodes: strips, grids

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Preoperative imaging – 3D reconstruction

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Neuronavigation-assisted electrode implantation

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Intraoperative electrophysiology

• EcOG

• SSEP

• Electric cortical stimulation:

Epileptogenic zone Speech mapping Memory mapping

Motor cortex mapping

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The extent of lateral resection in the dominant hemisphere

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The extent of hippocampal and parahippocampal resection

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Morell’s subpial transsection in the surgery of eloquent areas

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Alternative surgical techniques in epilepsy treatment Stimulation of the vagus nerve:

in case of high frequency (50Hz) stimulation there is a 50% reduction of CPS in 35% of patients

in case of low frequency (1-2Hz) stimulation there is an 80% reduction of CPS in 10% of patients

Stimulation of the right vagus nerve trigger more often bradycardia.

Stimulation of the CM nucleus of the thalamus:

there is no twofold blind prospective examination, the

number of patients participating is low

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Antiepileptic neuromodulatory procedures

rTMS

Peripheral neuro-

stimulation

Central neuro- stimulation

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Alternative surgical techniques in epilepsy treatment Stimulation of the cerebellum:

bilateral, extratemporal epilepsy, there is a 76%

improvement, 27% of patients becomes seizure free, and 44% show reductions in the number of seizures Stimulated region: vermis, interspherial surface

Stereotaxic amygdalotomy:

not used

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Stimulation of the white matter Vagus Nerve Stimulation (VNS)

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Cortical stimulation: open/closed loop techniques and local/remote approaches

Nagel, Najm 2009 Neuromodulation

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Cortical stimulation

>100Hz, closed-loop

Direct focus stimulation, preventing the seizure

RNS-Neuropace

– 45% reduction in the

seizures

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Epilepsy surgery – human experimental research

87654 8 76 5 4

9 1110 1216151413

12 9

16 13 ME1 ME2

=resection P=premotor

Connecting cable

Cortical lamination

Histology slide

Penetration track Electrode shaft

Recording site Tip

ME1 ME2

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